Chapter 5: Oral Surgery Introduction


Sinus Openings Introduction



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Sinus Openings

Introduction


Another complication of oral surgery is the accidental creation of an opening into the sinus. This may be the result of a root fracture or displacement of a maxillary third molar.

Prevention


To avoid this complication you should determine from preoperative radiographs if an opening into the sinus is likely (e.g., a solid molar resting against a thin walled large maxillary sinus). When there is a likelihood of such openings, controlled tooth division may be the treatment of choice.

Reacting to an Opening in the Sinus


If you do create an opening into the sinus, the most important step is to place the patient on a sinus regimen consisting of the following:

  • antibiotics: amoxicillin is a good first choice

  • nasal spray: Afrin or Neo-synephrine (short term only-prevent rebound effect)

  • having patient avoid blowing nose and sneeze with mouth open for up to three weeks

  • nasal decongestants

This helps keep the sinus free of congestion and possible secondary infections.

Note: If an infection can be avoided, the sinus opening will often close spontaneously. Also, if a secondary procedure is necessary to close the sinus, it is much more likely to be successful if an infection has been avoided.

The patient should be followed and examined weekly to see if closure has occurred (i.e., no reflux of fluids in the nose when drinking or drainage from the opening).

If closure has not occurred in 2 or 3 weeks, a secondary procedure is necessary.

Tuberosity Fractures

Introduction


Tuberosity fractures, another complication of oral surgery, are most commonly caused by excessive force during removal of maxillary second and third molars.

Prevention


When removing teeth the surgeon should keep the tooth and surrounding soft tissues visible at all times and should palpate these areas as pressure is applied. It is important to recognize the fracture immediately, while it is occurring, so that soft tissue and bone can be saved.

Reacting to a Tuberosity Fracture


You should attempt to section the tooth from the fracture segment. If the segment remains attached to periosteum, it should be retained and stabilized with sutures. If you can not separate the tooth from the bony segment, then the overlying soft tissue should be reflected from the bony segment. This is to ensure that the bone and the attached mucosa are not removed with the tooth leaving a large sinus opening that may be difficult to close.

Bleeding

Introduction


Bleeding, whether primary or secondary, is another complication that can be anticipated and planned for by the surgeon.

Definitions


Primary bleeding is bleeding associated with the operation. This type of bleeding should present no serious problem.

Secondary bleeding is bleeding that occurs hours or days following a surgical procedure.

Prevention


The best way to avoid complications is to:

  • give good postoperative instructions

  • control the bleeding before the patient is discharged

Reacting to Primary Bleeding


To control primary bleeding use the following:

  • local anesthesia

  • clamps

  • sutures

  • packing

Procedures for Reacting to Secondary Bleeding


To control secondary bleeding perform the following steps:

Step

Action

1

Clean the area removing any liver clots that may have formed.

2

Examine the patient and determine the source of bleeding. (Direct pressure with a

gloved finger to pinpoint the location of the bleeder if it is in the soft tissue.)



Note: You will need good lighting and suction.

3

Place a moist gauze sponge over the area with pressure for 15 minutes.

4

If still bleeding, reinject the area with a local anesthetic solution which contains a vasoconstrictor.

5

If still bleeding, apply one or more sutures as necessary.

6

If bleeding is from socket, pack the socket.

7

Request a bleeding workup if bleeding persists or if a coagulation defect is a possibility.

Aspiration/Swallowing of Foreign Objects

Introduction


Aspiration of foreign material, such as roots, teeth, restorations, sponges, cotton rolls, dentures, drains, etc., occurs and causes obstruction. Practitioners should be constantly aware that they are operating adjacent to the airway and that aspiration and obstruction are constant hazards.

Prevention


To prevent aspiration or swallowing of a foreign object during oral surgical procedures, a properly placed pharyngeal screen is important. This can usually be done by unfolding a 4 inch by 4 inch gauze and placing it between the surgical area and the posterior pharyngeal area.

Locating Aspirated/ Swallowed Objects


If an object is lost in the posterior pharyngeal area, its location (whether it was aspirated or swallowed) must be determined radiographically. In each case, chest and flat plane abdominal radiographs should be ordered.

Reacting to Aspirated Objects


If the object is in the lung, the patient should be referred immediately to the appropriate medical personnel so it can be removed by bronchoscopy or an open thoracotomy to avoid the formation of lung abscess.

Reacting to Swallowed Objects


If the object is swallowed, it should be followed with radiographs to determine its complete passage.

Nerve Injury

Introduction


Injury to the inferior alveolar nerve and to the lingual nerve can and do occur with even the best clinicians. Before mandibular impaction surgery or surgery around the mental foramen is done, the possibility of injury to the nerves must be discussed with the patient.

Procedures for Reacting to Nerve Injury


Perform the following steps when reacting to a nerve injury:

Step

Action

1

Examine the involved area as follows:

Substep

Action

a

Perform a two-point discrimination using calipers.

b

Perform a directional discrimination using light brush strokes with a cotton tip applicator

c

Perform a sharp and dull point discrimination.

d

If there is a disruption of the taste sensation, map out the disruption of tongue for future reference.

2

Chart the initial extent of the injury as follows:

Substep

Action

a

Draw a picture of the involved area in the chart.

b

Record or map out the test results on the picture.

3

If no improvement in 3 to 6 months, consider specialty consultation.

Consultation


If you do not feel comfortable evaluating the injury, or if you do not see improvement in 3 to 6 months, refer the patient for specialty consultation.

TMJ Injury

Introduction


Many patients with TMJ problems state that their first episode of symptoms occurred following a dental extraction, typically of a mandibular tooth.

Prevention


Dentists should recognize this potential and take the following steps:

  • Obtain a history of any significant TMJ dysfunction prior to any oral surgical procedure.

  • Advise patients who have preexisting TMJ dysfunction that an oral surgical procedure may cause additional joint symptoms or damage.

  • Minimize force placed on the joint and how wide and how long the mouth is opened. (See below.)

Techniques for Minimizing Force


Techniques for minimizing the amount of force placed on the TMJ include:

  • use of a rubber bite block for any mandibular procedure

  • use of the least amount of force possible for any mandibular extraction.

Note: It is often appropriate to surgically remove difficult mandibular teeth to minimize the amount of force required. This is particularly important in patients with preexisting TMJ symptoms.

Postoperative Pain

Introduction


Pain, swelling, and stiffness are expected the first 48 to 72 hours following surgery and are in direct proportion to the severity and length of the procedure accomplished. After 72 hours you should start to see a decrease in these components; if they persist, it is usually a sign of an underlying problem. The patient should then be examined clinically and radiographically.

Causes of Continued Postoperative Pain


The following conditions are some of the common causes of persistent pain following tooth extraction:

  • postoperative infection

  • localized osteitis (dry socket)

  • retention of root, bone, or foreign body

  • alveolar plate fracture

  • maxillary sinus problems

  • adjacent teeth

  • muscle spasms

  • nondental origin

Treatment for each of these causes follows.

Postoperative Infection Treatment


Treat postoperative infections with appropriate antibiotics and drainage if indicated.

Localized Osteitis (Dry Socket) Symptoms


Localized Osteitis usually occurs 3 to 5 days following extraction of a mandibular tooth with the third molar site being the most common. The following symptoms exist:

  • The patient will complain that analgesics do not help the pain and that the pain radiates
    to the ear.

  • There is a characteristic foul odor.

  • The patient also complains of a bad taste.

The process usually last 7-10 days or until granulation tissue covers the exposed bone.

Localized Osteitis (Dry Socket) Treatment


Treat for localized osteitis as follows:

Step

Action

1

Irrigate the socket thoroughly with saline.

2

Dress the socket with a dressing consisting of Iodoform gauze saturated with eugenol

(or one of the commercially available mixtures).



Note: This dressing will last 24 to 48 hours

3

Redress the socket as necessary. (You may need to redress it several times.)

Note: The dressing should be removed and the patient reevaluated in ten minutes. If the pain does not return, the socket likely does not require redressing.

Treatment for Retention of Root, Bone, or Foreign Body


The extraction site should be examined clinically and radiographically for any extraneous fragments. They may appear within the socket or between the alveolar plate and the mucosa.

Alveolar Plate Fracture Treatment


The socket should be examined for evidence of alveolar plate fracture (i.e., palpate for mobility). Small fragments of bone may need to be removed, but larger ones with periosteal attachment can be left and supportive care given until symptoms resolve.

Treatment for Maxillary Sinus Problems


Persistent pain in maxillary posterior teeth after surgery may be the results of sinusitis. The sinus should be evaluated clinically and radiographically and treated with appropriate antibiotics and surgical intervention when necessary.

Treatment for Pain from Adjacent Teeth


The teeth adjacent to an extraction site should be examined to determine whether the pain is arising from another tooth or associated tissues.

Causes of Muscle Spasms


Postoperative pain may be caused by:

  • prolonged mouth opening during the procedure

  • aggravation of a chronic or subchronic TMJ problem or trismus from where the surgery was done

  • local anesthetic injection

Treatment for Muscle Spasms


Treatment for muscle spasms should be directed toward--

  • obtaining muscle relaxation

  • reducing inflammation in the muscle

This is accomplished with:

  • heat to the area

  • ibuprofen or other nonsteroidal anti-inflammatory drugs that reduce pain and inflammation

  • range of motion stretching exercises to regain maxilla/mandible function and reduce swelling within the muscle

Treating Pain from Non-Dental Origin


  • Facial pain may persist after an extraction and have no obvious dental source. If you have done a thorough dental examine and ruled out dental factors, consider a facial neuralgia.

Chapter 5 5-

Oral Surgery July 2003





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